Markov chain decision model for urinary incontinence procedures.

Purpose Urinary incontinence (UI) is a common chronic health condition, a problem specifically among elderly women that impacts quality of life negatively. However, UI is usually viewed as likely result of old age, and as such is generally not evaluated or even managed appropriately. Many treatments are available to manage incontinence, such as bladder training and numerous surgical procedures such as Burch colposuspension and Sling for UI which have high success rates. The purpose of this paper is to analyze which of these popular surgical procedures for UI is effective. Design/methodology/approach This research employs randomized, prospective studies to obtain robust cost and utility data used in the Markov chain decision model for examining which of these surgical interventions is more effective in treating women with stress UI based on two measures: number of quality adjusted life years (QALY) and cost per QALY. Treeage Pro Healthcare software was employed in Markov decision analysis. Findings Results showed the Sling procedure is a more effective surgical intervention than the Burch. However, if a utility greater than certain utility value, for which both procedures are equally effective, is assigned to persistent incontinence, the Burch procedure is more effective than the Sling procedure. Originality/value This paper demonstrates the efficacy of a Markov chain decision modeling approach to study the comparative effectiveness analysis of available treatments for patients with UI, an important public health issue, widely prevalent among elderly women in developed and developing countries. This research also improves upon other analyses using a Markov chain decision modeling process to analyze various strategies for treating UI.

Complementary and Alternative Medicine Use in the US Adult Low Back Pain Population.

BACKGROUND: Many people suffering from low back pain (LBP) have found conventional medical treatments to be ineffective for managing their LBP and are increasingly turning to complementary and alternative medicine (CAM) to find pain relief. A comprehensive picture of CAM use in the LBP population, including all of the most commonly used modalities, is needed. STUDY OBJECTIVE: To examine prevalence and perceived benefit of CAM use within the US LBP population by limiting vs nonlimiting LBP and to evaluate the odds of past year CAM use within the LBP population. METHODS: Data are from the 2012 National Health Interview Survey, Alternative Health Supplement. We examined a nationally representative sample of US adults with LBP (N=9665 unweighted). Multiple logistic regression was used to estimate the odds of past year CAM use. RESULTS: In all, 41.2% of the LBP population used CAM in the past year, with higher use reported among those with limiting LBP. The most popular therapies used in the LBP population included herbal supplements, chiropractic manipulation, and massage. The majority of the LBP population used CAM specifically to treat back pain, and 58.1% of those who used CAM for their back pain perceived a great deal of benefit. CONCLUSION: The results are indicative of CAM becoming an increasingly important component of care for people with LBP. Additional understanding of patterns of CAM use among the LBP population will help health professionals make more informed care decisions and guide investigators in development of future back pain-related CAM research.

Complementary and integrative healthcare for patients with mechanical low back pain in a U.S. hospital setting.

OBJECTIVES: Complementary and integrative healthcare (CIH) is commonly used to treat low back pain (LBP). While the use of CIH within hospitals is increasing, little is known regarding the delivery of these services within inpatient settings. We examine the patterns of CIH services among inpatients with mechanical LBP in a hospital setting. METHODS: This is a retrospective, practice-based study conducted at Abbot Northwestern hospital in Minnesota. Using electronic health record data from July 2009 to December 2012, 8095 inpatients with mechanical LBP were identified using ICD-9 codes. We classified patients by reason for hospitalization. We examined demographic and clinical characteristics by receipt of CIH services. Then, we estimated the prevalence of types of CIH delivered and clinical foci for CIH visits among inpatients with mechanical LBP. RESULTS: Most inpatients with mechanical LBP (>90%) were hospitalized for surgical procedures. Overall, 14.2% received inpatient CIH services. All demographic and clinical characteristics differed by receipt of CIH (P<0.001), except race/ethnicity. CIH recipients were in poorer health than those who did not. Most commonly delivered CIH services were massage (62.1%), relaxation techniques (42.0%) and acupuncture (25.7%). Pain (45.1%), relaxation (17.5%), and comfort (8.2%) were the top three reasons for CIH visits. CONCLUSION: There are important differences between CIH recipients and non-CIH recipients among patients with mechanical LBP within a hospital setting. The reasons documented for CIH visits included addressing physical, emotional and/or mental conditions of patients. Future studies are needed to determine the effectiveness of CIH services health and wellbeing outcomes in this population.

Complementary and Alternative Medicine Use among Women of Reproductive Age in the United States.

BACKGROUND: The purpose of this study was to examine the prevalence of complementary and alternative medicine (CAM) use, types of CAM used, and reasons for CAM use among reproductive-age women in the United States. METHODS: Data are from the 2007 National Health Interview Survey. We examined a nationally representative sample of U.S. women ages 18 to 44 (n = 5,764 respondents). Primary outcomes were past year CAM use, reasons for CAM use, and conditions treated with CAM by pregnancy status (currently pregnant, gave birth in past year, neither). Multivariate logistic regression was used to estimate the odds of CAM use by pregnancy status. FINDINGS: Overall, 67% of reproductive-age U.S. women reported using any CAM in the past year. Excluding vitamins, 42% reported using CAM. Significant differences in use of biologically based (p = .03) and mind-body therapies (p = .012) by pregnancy status were found. Back pain (17.1%), neck pain (7.7%), and anxiety (3.7%) were the most commonly reported conditions treated with CAM among reproductive-age women. However, 20% of pregnant and postpartum women used CAM for pregnancy-related reasons, making pregnancy the most common reason for CAM use among pregnant and postpartum women. CONCLUSIONS: CAM use during the childbearing year is prevalent, with one-fifth of currently or recently pregnant women reporting CAM use for pregnancy-related reasons. Policymakers should consider how public resources may be used to support appropriate, effective use of alternative approaches to managing health during pregnancy and postpartum. Providers should be aware of the changing needs and personal health practices of reproductive age women.

Differences in diabetes self-care activities by race/ethnicity and insulin use.

PURPOSE: The purpose of this study is to examine differences in diabetes self-care activities by race/ethnicity and insulin use. METHODS: Data were from the 2011 Behavioral Risk Factor Surveillance System for adults with diabetes. Outcomes included 5 diabetes self-care activities (blood glucose monitoring, foot checks, nonsmoking, physical activity, healthy eating) and 3 levels of diabetes self-care (high, moderate, low). Logistic regression models stratified by insulin use were used to estimate the odds of each self-care activity by race/ethnicity. RESULTS: Only 20% of adults had high levels of diabetes self-care, while 64% had moderate and 16% had low self-care. Racial/ethnic differences were apparent for every self-care activity among non-insulin users but only for glucose monitoring and foot checks among insulin users. Overall, American Indian / Alaska Natives had higher odds of glucose monitoring; blacks had higher odds of foot checks; and Hispanics had higher odds of not smoking compared with non-Hispanic Whites. Non-insulin-using American Indian / Alaska Natives had higher odds of foot checks, and non-insulin-using Hispanics had higher odds of fruit/vegetable consumption. CONCLUSIONS: Participation in specific diabetes self-care behaviors differs by race/ethnicity and by insulin use. Yet, few adults with diabetes of any race/ethnicity engage in high levels of self-care. Findings suggest that culturally tailored messages about diabetes self-care may be needed, in addition to more effective population promotion of healthy lifestyles and risk reduction behaviors to improve diabetes control and overall health. Diabetes educators can be a catalyst for adopting a population approach to diabetes management, which requires addressing both prevention and management of diabetes for all patients.

End-tidal carbon dioxide as a measure of stress response to clustered nursing interventions in neurologic patients.

BACKGROUND: Guidelines recommend rest periods between nursing interventions for patients with a neurologic diagnosis but do not specify a safe number of interventions. OBJECTIVES: To examine the physiological stress response to clustered nursing interventions in neurologic patients receiving mechanical ventilation. METHODS: Prospective, comparative, descriptive design to examine effects of clustered interventions (≥6 interventions in a single nursing interaction) versus nonclustered interventions on patients' stress. Stress response was defined as a 10% change in end-tidal carbon dioxide from before the interaction to (1) 5 and 10 minutes after the start of the interaction, (2) at the end of the interaction, and (3) 15 minutes after the interaction. RESULTS: The mean percent change in end-tidal carbon dioxide at 5 minutes differed significantly between patients with clustered interventions and patients with nonclustered interventions (6.7% vs -0.2%; P = .001). Patients with clustered interventions were significantly more likely than patients with low clustering to exhibit a stress response at 5 minutes (24.3% vs 0%; P = .01). CONCLUSIONS: Neurologic patients receiving mechanical ventilation who experienced 6 or more clustered nursing interventions showed a higher mean change in end-tidal carbon dioxide than did patients who received fewer than 6 clustered interventions. These findings suggest that providing fewer interventions during 1 nursing interaction may minimize induced stress in neurologic patients receiving mechanical ventilation.

Disparities in potentially avoidable emergency department (ED) care: ED visits for ambulatory care sensitive conditions.

INTRODUCTION: Hospital care for ambulatory care sensitive conditions (ACSC) is potentially avoidable and often viewed as an indicator of suboptimal primary care. However, potentially preventable encounters with the health care system also occur in emergency department (ED) settings. We examined ED visits to identify subpopulations with disproportionate use of EDs for ACSC care. METHODS: We analyzed data from the 2007-2009 National Hospital Ambulatory Medical Care Survey for 78,114 ED visits by adults aged 18 and older. Outcomes were ACSC visits determined from the primary ED diagnosis. We constructed analytic groups aligned with Agency for Healthcare Research and Quality's priority populations. Multivariate logistic regression was used to estimate the odds of all-cause, acute, and chronic ACSC visits. We used Stata SE survey techniques to account for the complex survey design. RESULTS: Overall, 8.4% of ED visits were for ACSC, representing over 8 million potentially avoidable ED visits annually. ACSC visits were more likely to result in hospitalization than non-ACSC visits (34.4% vs. 14.0%, P<0.001). Multivariate models revealed significant disparities in ACSC visits to the ED by race/ethnicity, insurance status, age group, and socioeconomic status, although patterns differed for acute and chronic ACSC. CONCLUSIONS: Disproportionately higher use of EDs for ACSC care exists for many priority populations and across a broader range of priority populations than previously documented. These differences constitute disparities in potentially avoidable ED visits for ACSC. To avoid exacerbating disparities, health policy efforts to minimize economic inefficiencies in health care delivery by limiting ED visits for ACSC should first address their determinants.

Examining quality and efficiency of the U.S. healthcare system.

PURPOSE: The fundamental concern of this research study is to learn the quality and efficiency of U.S. healthcare services. It seeks to examine the impact of quality and efficiency on various stakeholders to achieve the best value for each dollar spent for healthcare. The study aims to offer insights on quality reformation efforts, contemporary healthcare policy and a forthcoming change shaped by the Federal healthcare fiscal policy and to recommend the improvement objective by comparing the U.S. healthcare system with those of other developed nations. DESIGN/METHODOLOGY/APPROACH: The US healthcare system is examined utilizing various data on recent trends in: spending, budgetary implications, economic indicators, i.e., GDP, inflation, wage and population growth. Process maps, cause and effect diagrams and descriptive data statistics are utilized to understand the various drivers that influence the rising healthcare cost. A proposed cause and effect diagram is presented to offer potential solutions, for significant improvement in U.S. healthcare. FINDINGS: At present, the US healthcare system is of vital interest to the nation's economy and government policy (spending). The U.S. healthcare system is characterized as the world's most expensive yet least effective compared with other nations. Growing healthcare costs have made millions of citizens vulnerable. Major drivers of the healthcare costs are institutionalized medical practices and reimbursement policies, technology-induced costs and consumer behavior. PRACTICAL IMPLICATIONS: Reviewing many articles, congressional reports, internet websites and related material, a simplified process map of the US healthcare system is presented. The financial process map is also created to further understand the overall process that connects the stakeholders in the healthcare system. Factors impacting healthcare are presented by a cause and effect diagram to further simplify the complexities of healthcare. This tool can also be used as a guide to improve efficiency by removing the "waste" from the system. Trend analyses are presented that display the crucial relationship between economic growth and healthcare spending. ORIGINALITY/VALUE: There are many articles and reports published on the US healthcare system. However, very few articles have explored, in a comprehensive manner, the links between the economic indicators and measures of the healthcare system and how to reform this system. As a result of the US healthcare system's complex structure, process map and cause-effect diagrams are utilized to simplify, address and understand. This study linked top-level factors, i.e., the societal, government policies, healthcare system comparison, potential reformation solutions and the enormity of the recent trends by presenting serious issues associated with U.S. healthcare.

Hospital cost structure in the USA: what's behind the costs? A business case.

PURPOSE: Hospital costs in the USA are a large part of the national GDP. Medical billing and supplies processes are significant and growing contributors to hospital operations costs in the USA. This article aims to identify cost drivers associated with these processes and to suggest improvements to reduce hospital costs. DESIGN/METHODOLOGY/APPROACH: A Monte Carlo simulation model that uses @Risk software facilitates cost analysis and captures variability associated with the medical billing process (administrative) and medical supplies process (variable). The model produces estimated savings for implementing new processes. FINDINGS: Significant waste exists across the entire medical supply process that needs to be eliminated. Annual savings, by implementing the improved process, have the potential to save several billion dollars annually in US hospitals. The other analysis in this study is related to hospital billing processes. Increased spending on hospital billing processes is not entirely due to hospital inefficiency. RESEARCH LIMITATIONS/IMPLICATIONS: The study lacks concrete data for accurately measuring cost savings, but there is obviously room for improvement in the two US healthcare processes. This article only looks at two specific costs associated with medical supply and medical billing processes, respectively. PRACTICAL IMPLICATIONS: This study facilitates awareness of escalating US hospital expenditures. Cost categories, namely, fixed, variable and administrative, are presented to identify the greatest areas for improvement. ORIGINALITY/VALUE: The study will be valuable to US Congress policy makers and US healthcare industry decision makers. Medical billing process, part of a hospital's administrative costs, and hospital supplies management processes are part of variable costs. These are the two major cost drivers of US hospitals' expenditures that were examined and analyzed.